Geriatric

1)Polypharmacy
According to Dorland's Medical Dictionary, 24th edition, polypharmacy (PP) is the concurrent use of several different drugs. Some authors have used the term co-pharmacy to characterise the appropriate and necessary combination of drugs, and only used the term PP for the inappropriate drug combinations. However, it can sometimes be difficult to decide whether a certain combination of drugs is appropriate or not. It depends on the type of drugs, the disease, the patient's ability to understand the importance of each drug treatment and the risk of compliance problems. For patients suffering from multiple diseases, and for certain conditions associated with a need for multiple drug treatment, eg congestive heart failure, hypertension, chronic obstructive lung disease, some psychiatric disorders, some infections and neoplastic diseases, PP may, from a clinical pharmacological point of view, be rational and necessary. Even if a multiple drug regimen is clinically appropriate, however, individuals exposed to multiple drugs deserve attention because of quality of care issues related to higher risk of adverse drug reactions, interactions, poor compliance and cost control issues.


In most studies the term polypharmacy has been used with negative connotations of adverse clinical outcomes. Thus, authors have used PP to denote treatments with excessive and unnecessary use of medications. This study have focused entirely on polypharmacy from a quantitative point of view. Individuals exposed to polypharmacy have thus been identified from the number of drugs in use, regardless of the clinical consequences of the drug combinations.

To date, little research has been conducted to determine the safety and efficacy of combining multiple medications in a single patient. Some researchers have suggested that research in pharmacology is not sophisticated enough at the present time to examine the effects of multiple medications taken at one time. Others have referred to polypharmacy as an uncontrolled experiment. They suggest that a scientist in a laboratory would never combine eight to 10 different chemicals at random in a test tube without first preparing for the consequences. Thus, when an elderly patient is prescribed eight to 10 medications concurrently, it is impossible to predict the outcome.

Medication interactions are far more likely to occur in the elderly than in the younger population primarily because older adults take more medications. With increased medications, the number of drug combinations increases exponentially. The number of possible two medication interactions for a regimen of n medications is calculated as n x (n- 1)/2.With two medications, there is only one possible pairing interaction, but five medications produces 10 possible pairings, and 10 medications produces 45 possible pairings. Additionally, some interactions develop from a combined effect of three or more medications in the regimen. Although not all medication interactions result in ADRs, the potential for ADRs further complicates medication therapy in elderly patients. Common medication interactions in elderly patients are listed in Table 1.
Table-1
Common Medication Interaction In The Elderly
Primary medication

Secondary medication
Antacids Cimetidine, chlorpromazine, digoxin, isoniazid, tetracycline, iron
Beta blockers Cimetidine, lidocaine, verapamil, diltiazem Cholestyramine Phenobarbital, warfarin, thiazides, thyroxin, digoxin, glycosides, acetylsalicylic acid, acetaminophen, penicillin Cimetidine Diazepam, warfarin, theophylline, propranolol, phenytoin, lidocaine Furosemide Antibiotics, prednisone, nonsteroidal anti-inflammatory drugs (NSAIDs) Heparin Acetylsalicylic acid
Iron Tetracycline Nitrates Nifedipine NSAIDs Loop diuretics, thiazide diuretics, beta blockers, angiotensin-converting enzyme inhibitors,  anticoagulants, oral hypoglycemics, digoxin Phenytoin Co-trimoxazole Tolbutamide Phenylbutazone, warfarin, salicylates Warfarin Interactions with multiple medications are common.

2)The Aged Through History
Today’s elders have offered the sacrifice, strength, and spirit that made this country great. They were the proud GIs in world wars, the brave immigrants who ventures into an unknown land, the bold entrepreneurs who took risks that creates wealth and opportunities for work, and the unselfish parents who struggled to give their children a better life. They have witnessed and participated in the most profound informational, technology, and social growth and change. They have earned respect admiration, and dignity. Today the elderly are viewed with positivism rather than prejudice, intelligence rather than myth, and concern rather than neglect. A brief reflection of the view of the old in past societies demonstrates that this positive view was not always the norm, however.

Historically, societies have reacted to their aged members in a variety of ways. In the time of Confucius, there was a direct correlation between a person’s age and the degree of respect to which he or she was entitled. Taoism viewed old as a epitome of life, and the ancient Chinese believed that attaining old age was a wonderful accomplishment that deserve great honor. On the other hand, the early Egyptians dreaded growing old and experimented with a variety of potions and schemes to maintain their youth. Opinions were divided among the early Greeks; myths portray many struggles between old and young. Plato promoted the aged as society’s best leaders, whereas Aristotle denied the elderly any role in government matters. Ancient Romans had limited respect for their elders; in the nations that Rome conquered, the sick aged were customarily the first to be killed.

Woven throughout the Bibles is God’s concern for the well-being of the family and desire for people to respect elders. The Dark ages were especially bleak for older persons; the middle Ages were did not bring considerable improvement. Strong feelings regarding the superiority of youth occurred during medieval times; these feelings were expressed in uprisings of sons against fathers. The art of this period, depicting figures such as Father Time, also portrayed an uncomplimentary image of older adults. The elderly were among the first to be affected by famine and poverty and the last to benefit from better times. In the early 17th century, England developed Poor Laws that provided care for the destitute and enabled older persons without family resources to have some modest safety net. Many gains in the treatment of the elderly that were made during the 18th and 19th centuries were lost because of the cruelties of the Industrial Revolution. Although child labor laws were developed to guard minors, the aged were left unprotected. Those unable to meet industrial demands were placed at the mercy of their offspring or forced to beg on the streets for sustenance.

Although Dr. I. L. Nascher, known as the father of geriatrics, wrote the first geriatric textbook in 1974, American literature during the first half of the 20th century reflects little improvement in the status of older adults. The first significant step in the improving the lives of older American was the passage of the Federal Old Age Insurance Law under the social security Act in 1953, which provided some financial security for elderly persons. The profound graying of the population started to be realized in the 1960s, and the United States responded with the formation of the Administration Act, and the introduction of Medicaid and Medicare, all in 1965. Since that time, society has demonstrated growing concern for its older members.

The past few decades have brought profound awakening of interest in older persons as their numbers in society have grown. A more humanistic attitude toward all members of society has also affected the aged, and improvements in health care and general living conditions ensure that more people have the opportunity to attain old age and live longer, more fruitful years in this segment of life than previous generations.

3)Development of Geronotological Nursing
Nurses, long interested in the care of aged, seem to have assumed more responsibility than other professional disciplines for this segment of the population. In 1904, the Americans Journal of Nursing printed the first Nursing article on the care of aged, presenting many principles that continue to guide geronotological nursing practice today. Bishop says “You must not treat a young child as you would a grown person, nor must you treat a old person as you would one in the prime life.” Interestingly, this same journal featured a article: The old Nurse,” which emphasized the value of ageing Nurse years of experience.

After the Federal old age Insurance law (better known as social security) was passed in 1953, many older person had an alternative to alms houses and could independently purchase room and board. Because many of the homes that offered these services for aged were operated by woman who called themselves Nurse, it is not the coincidental that such residence later became known as nursing homes.

For many years, care of the aged was an unpopular branch of nursing practice. Geriatrics nurses were thought to be somewhat inferior in capabilities, neither good enough for acute setting nor ready to “go to pasture.” Geriatric facilities may have further discouraged many competent nurses from working in these setting by paying low salaries. Little existed to counter the negativism in educational programs, where experiences with older person were inadequate in both quantity and quality, and attention focused on the sick rather than the well, which were more representative of the older population. Although nurses were among the few professionals involved with aged, gerontology was missing from the most nursing curriculums until recently.

Frustration over the lack of value placed on geriatric nursing led to the appeal to the American Nursing Association (ANA) for assistance in promoting the status of this area of practice. After a year of study in 1961 the ANA recommended that a specialty groups for geriatrics nurses be formed. In 1962 The ANA conference group on Geriatrics Nursing Practice held its first national meeting. This group became the division of Geriatric Nursing in 1996, gaining full recognition as nursing specialty. An important contribution by this group was the development in 1969 of Standard for Geriatrics Nursing Practice, first published in 1970. Certification of nurses for excellence in geriatric nursing practice followed, with the first 74 nurses achieving this recognition in 1975.The birth of the journal of the Gerontological Nursing, the first professional journal to meet the specific needs and interests of gerontological nurses, also occurred in 1975.

Through the 1970s, nurses began to become increasingly aware of their role in promoting a healthy ageing experience for all individual and ensuring the wellness of older adults. As a result, they expressed interest in changing the name of the specialty from geriatric to gerontological nursing to reflect a broader scope than the care of ill aged. IN 1976, the Geriatric Nursing Division became the Gerontological Nursing Division.

In past few decades, the specialty of gerontological nursing has experience profound growth. Whereas only 32 articles on the topic of the nursing care of the aged were listed in Cumulative Index to Nursing Literature in 1956, and only twice that number appeared a decade later, the numbers of articles published yearly more than doubled thereafter. Gerontological nursing text grew from a few to the 1960s to a few dozen in 1970s, and the quantity and quality of this literature has been rising since. Growing numbers of nursing school are included gerontological nursing course in their undergraduate programs and offering advanced degrees with a major in this area. To date, over 12,000 nurses have become certified in gerontological nursing practice. Nursing administration in long term care, geropsychiatric nursing, geriatric rehabilitation, and other areas of sub specialization have evolved. The specialty has indeed advanced rapidly, and all indications are that this growth will continue.

Along with the growth of the specialty has been a heightened awareness of the complexity of gerontological nursing. Elderly people exhibit great diversity in terms of health status, cultural background, life-style, living arrangement, socioeconomic status, and other variables. Most have chronic conditions that uniquely affect acute illness, reactions to treatments, and quality of life. Symptoms of illness can be atypical. Multiple health conditions can coexist and muddle the ability to chart the courses of a single disease or identity the underlying cause of symptoms. The conditions that older adults experience can cut across many clinical specialties, thereby challenging gerontological nurse to have abroad knowledge base. The risk for complication is high. Other factors, such as limited finance or social isolation, affect the state of health and well being. Also, the elective status of geriatrics in many medical and nursing schools can limit the pool of colleagues who are knowledgeable about the unique aspect of caring for the elderly.

Geronotological Nursing Roles:
In their activities with older adults, nurse function in a variety of roles, most of which following categories.

a) Healer
Early nursing practice was based on the Christian concept of the intertwining of the flesh and spirit. In the mid -1800s nursing’s role as a healing art was recognized; this is a apparent through Florence Nightingale’s writing that nursing “put the patient in the best condition for nature to act upon him”. Although the early emphasis on nurturance, comfort, empathy, and intuition was replaced by detachment, objectivity, and scientific approaches as medical knowledge and technology grew more sophisticated, the revival of the holistic approach to health care has enabled nurses to again recognize the interdependency of body, mind, and spirit in health and healing. Nursing plays a significant role in helping individuals stay well. Overcome or cope with disease, restore function, find meaning and purpose in life, and mobilize external and internal resource. In the healer role, the gerontological nurses recognize that most human being value health, are responsible active participants in their health maintenance and illness management, and desire harmony and wholeness with their environment. A holistic approach is essential, recognizing that older individuals must be viewed in the context of their biologic, emotional, social, cultural, and spiritual elements.
b) Caregiver

The major role filled by nurses is that of caregiver. In this role, gerontological nurses use gerontological theory in the conscientious application of the nursing process to the care of elders. Inherent in this role is the active participation of the older adults and their significant others and promotion of the highest degree of self care of the elderly.

Although the body of knowledge of geriatrics and gerontological care has grown considerably, many practitioners are lacking in this information. Gerontological nurses are challenged to ensure that the care of older adults is based on the sound knowledge that reflects the unique characteristics, needs, and responses of the elderly by disseminating gerontological principles and practices.

c) Educator
Gerontological nurses must be prepared to take advantage of formal and informal opportunities to share knowledge and skills related to the care of older adults. This education extends beyond professional to the general public. Areas in which gerontological nurses can educate others include normal aging, pathophysiology, geriatrics, pharmacology, and resource. Essential to this role is effective communication involving listening, interaction, clarifying, validating, and evaluating.
d)Advocate
Gerontological nurse can function in this role in several ways. First and foremost, advocacy for individual clients is essential and can include aiding older adults in asserting their rights and obtaining required services, facilitating of communities or other groups efforts to affect change and achieve benefits for older adults, and promoting gerontological nursing and new and expanded roles of nurses in this specialty.
e)Innovator
Gerontological nursing continues to be an evolving specialty; therefore, opportunities exist to develop new technologies and different modalities of care delivery. As an innovator, the gerontological nurse assumes an inquisitive style, making conscious decisions and effort to experiment for end result of improved gerontological practice. This requires the nurse to be willing to think “out of the box” and take risks associated with traveling down new roads, transforming visions into reality. These roles can be actualized in a variety of practice settings, and offer opportunities for gerontological nurses to demonstrate significant creativity and leadership.
f)Standard:
Professional nursing practice is guided by standards. Standards reflect the level and expectation of the care that are desired and serve as a model against which practice can be judged. Thus, standards serve to both guide and evaluate nursing practice.

Standards arise from variety of sources. State and federal regulations outline minimum standard of practice for various health care workers (example Nurse Practice Acts) and agencies (eg. Nursing Homes). The joint commission on Accreditation of health care organization has developed standards for various clinical settings that strive to describe the maximum attainable performance level. The ANA Standard of Gerontological nurses are unique in that they are only standards developed by and for Gerontological nurses. Nurses must regularly evaluate their actual practice against all standards governing their practice area to ensure their actions reflect the highest quality care possible.

Principles Guiding Gerontological Nursing Practice
Scientific data regarding theories, life adjustments, normal aging, and pathophysiology of aging are combined with selected information from psychology, sociology, biology, and other physical and social science to provide specialized care to the older population. Professional nurses are responsible for using these scientific data as the foundation for nursing practice and ensuring through education and managerial means that other care givers use a sound knowledge base.

Data from a variety of disciplines are incorporated in the development of nursing principles, or those proven facts or theories that are accepted by society and that guide nursing actions. In addition to the basic principles that direct the delivery of care to persons in general, specific and unique principles are used in caring for individuals of certain age groups and those who possess particular health problems. Some of the principles guiding Gerontological nursing practice are discussed below;

Aging is a Natural process common to all living organisms:
Every living organism begins aging from the time of conception. The process of maturing or aging helps the individual achieve the level of cellular, organ and system function necessary for the accomplishment of life tasks. Constantly and continuously, every cells of every organism ages. Despite the normality and naturalness of this experience, many people approach aging as though it were a pathologic experience,. Witnessed by comments that associates aging with:

Looking gray and wrinkled.

Losing one's mind.

Become sick and frail.

Obtaining little satisfaction from life.

Returning to child like behavior.

Being useless.

Various factors influence the aging process :
Heredity, nutrition, health status, life experiences, environment, activity, and stress produce unique effects in each individual. Among the variety of factors either known or hypothesized affect the usual pattern of ageing, inherited factors are believed by some researchers to determine the rate of ageing. Malnourishment can hasten the ill effects of the aging process, as can exposure to environment, toxins, diseases and stress. On the other hand, mental, physical and social activity can reduce the rate and degree of declining function with age.

Every person’s age in an individualized manner, although some general characteristics are evident among most people in a given age category. Just as we would not assume that all thirty year old people are identical and would evaluate, approach and communicate with each person in an individualized manner. We must recognize that no two persons 60, 70, or 80 years of age are alike. Nurse must understand the multitude of factors that influence the aging process and recognize the unique outcomes for each individual.
Unique Data and knowledge are used in applying the nursing process to the older population.

In nursing, the elderly, scientific data related to normal aging and the unique psychological, biological, social, and spiritual characteristics of the older person are integrated with the general knowledge of nursing. The nursing process provides a systematic approach to the delivery of nursing service and integrates wide range of knowledge and skills. The scope of nursing includes more than following a medical order or performing an isolated task; the nursing process involves a holistic approach to individuals and the care they require. The unique physiologic, psychological, social and spiritual challenges of the elderly are considered in every phase of the nursing process.

The elderly share similar universal self care demands with all other human beings.

a.Using Dorothea Orem’s self care theory 1980 as a basic framework, these demands are:

Ventilation and circulation.

Nutrition

Excretion

Activity and exercise

Sleep and rest

Solitude and connection

Safety

Normality

b.Through self care practices, people usually perform activities independently and voluntarily to meet these life demands. When an unusual circumstance interferes with an individual ability to meet these demands, nursing intervention could be warranted. The requirement for those needs and specific problems that the elderly may experience in fulfilling them.

c. Gerontological nursing strives to help older adults achieve optimal level of physical, psychological, social and spiritual health so that they can achieve wholeness.

d. One can view aging as the process of realizing one’s humanness, wholeness and unique identity in an ever changing world. In late life, people achieve a sense of personhood that allows them to demonstrate individuality and move toward self actualization. By doing so, they are able to experience harmony with their inner and external environment, realize their self worth, enjoy full and deep social relationships, achieve a sense of purpose and develop the many factors of their being. Gerontological nurses play an important role in helping people achieve wholeness. Within the framework of the self care theory, nursing actions towards the goal are:

 Strengthening the individual’s self care capacity.

 Eliminating or minimizing self care limitation.

 Providing direct services by acting for, doing for, or assisting the individual when demands cannot be met independently.

e.The thread woven throughout the above nursing actions is the promotion of maximum independence. Although it may be more time consuming and difficult allowing older persons to do as much for themselves as possible produces many positive outcomes for their bio-psychological health.

Holistic Gerontological care

Holism refers to the integration of the biologic, psychological, social and spiritual dimension of an individual to form a sum that is greater than its parts. Holistic Gerontological care incorporates knowledge and skills from a variety of disciplines. Holistic Gerontological care is connected with:

 Facilitating growth towards wholeness.

 Promoting recovery from an illness.

 Maximizing quality of life when one possesses an incurable illness or disability.

 Providing peace, comfort and dignity as death is approached.

In holistic care, the goal is not to treat disease but to serve the needs of the total person to the healing of the body, mind and spirit.

Health promotion and healing through a balance of the body, mind and spirit of individuals are at the core of holistic care. This concern has relevance for Gerontological care. The impact of age related changes and the effects of the highly prevalent chronic condition easily can threaten the well being of body, mind and spirit; therefore, nursing interventions to reduce such threats are essential. Because chronic diseases and the effects of advanced age cannot be eliminated, healing rather than curative efforts will be those most beneficial in Gerontological nursing practice. Equally significant is assisting older adults toward self discovery in their final phase of their life so that they can find meaning, connectedness with others and understanding of their place in the universe.

3)The Need for Age-friendly Primary Health Care

The demographic imperative
A demo¬graphic revolution is under way throughout the world. Today there are about 600 mil¬lion people in the world aged 60 and over. By 2025 this total is expected to double and by 2050 it is projected to reach two billion or 21 percent of the total global population. Such accelerated global population ageing will impact social and health care demands in all countries.

Population ageing is driven by two factors: an increase in the proportion of adults aged 60 and over as mortality rates decline, and a decline in the proportion of children reflecting declines in total fertility rates (TFR) in the overall population. Today over 60 percent of the world’s older persons 60 and over live in the developing world. By 2025 that figure will rise to 75 percent and 85 percent in 2050. However, the speed and impact of population ageing in the less de-veloped regions are yet to be fully appreci¬ated. Moreover, among the older population worldwide, the fastest growing group is the oldest old, those who are 80 years or more.

By 2025 in countries such as China, Brazil and Thailand, the proportion of older people will be above 15 percent while in Indonesia, Colombia and Kenya the abso¬lute numbers will increase by up to 400 percent in the next 25 years, i.e. up to eight times higher than the increases experi¬enced by already aged societies in Western Europe where population ageing occurred over a much longer period of time.

The epidemiological transition
The de¬veloping world continues to face the bur¬den of persistent infectious diseases while the prevalence of risk factors for chronic diseases is also on the increase – all within the context of under-resourced health and social systems. Although many individuals can now look forward to longer lives, the risk of having at least one chronic disease, such as hypertension or diabetes, increases with age. This is not so much a function of chronological age per se but a reflection of the life-long accumulation of risk factors for such diseases which reinforces the im¬portance of health promotion and disease prevention throughout the life course.

Patterns that lead to disabilities and chron¬ic illnesses are costly in economic and human terms to individuals, families and society. A life course approach including healthy lifestyles and due recognition of the impact of environmental, socio-economic and other conditions, can break the cycle that leads to many disabling diseases later in life.

Ageing is definitely no longer a first world issue. What was a footnote in the 20th century is on its way to becoming a domi¬nant theme in the 21st.

(Kofi Annan, UN Secretary General)

4)Depression
The European Region has the highest prevalence of older people, with 15% of the population 65 and over and nearly 7% 75 years and over in 2000. By 2030 these will increase to 24% and 12% respectively. Over the next 30 years, the projected rate of increase in the older population in European countries will vary considerably, from 14% in Bulgaria to 87% in Luxembourg. Of the 20 countries in the world with the highest age index scores (the number of people aged 65 and cover per 100 under age 15), 17 were located in Europe in 2000. The initial development of old-age mental health services in Europe occurred in the UK, prompted by the ageing population.

The increase in the proportion of people over 75 is likely to have the greatest impact upon mental health service delivery, as the effects of population ageing are amplified by a disproportionate increase in dementia. According to the WHO World Health Report 2001, dementia was the thirteenth leading cause of years lived with a disability in the world in 2000, and it is projected to rapidly increase its contribution to the global burden of disease over the next 20 years, particularly in developed countries. The Behavioral and Psychological Symptoms of Dementia (BPSD) are the major aspect of dementia care that fall within the expertise of old-age mental health services and it has been estimated that 32% cases would potentially benefit from their involvement. Depression is also common in old-age though there is conflicting evidence about its prevalence in the community, with reported rates ranging from 2% to 15% in those over 65. Other mental disorders of major concern in old-age include anxiety, schizophrenia, substance abuse disorders and delirium.

Hence there is an imperative to determine the effectiveness of old-age mental health services to ensure high-quality care for the growing aging population. To address this question, this synthesis presents evidence covering all aspects of care for older people with mental disorders, covering effective treatments, models of care and different service delivery settings.

Ageing is a progressive state, beginning with conception and ending with death, which is associated with physical, social and psychological changes. there has been a considerable increase in the absolute and relative numbers of older people in the world population of both developed and developing countries in the 20th century. As a result of reduction in both mortality and fertility; where fewer children are born and more people reach old age, Of the approximately 580 million elderly people (60 years and above) in the world, around 335 million live in developing countries. Nowadays, the life expectancy in more than 20 developing countries is 72 years or above.

Chronological definition of elderly in Malaysia includes people aged 60 years and older. The proportion of elderly in Malaysia is increasing due to significant socioeconomic and demographic transformation. The determinants of ageing in our country are also due to reductions in fertility and mortality. The elderly population increased from 5.9% in 1991 to 6.5% in 2000. The expected proportion of people age 60 and above in year 2020 is 9.5%.

The increases in life expectancy have brought about increased numbers of certain illnesses, one of the major ones being chronic mental illnesses. In both industrialized nations of the West and developing countries of Asia, Africa and America Latin, the problem of mental illness among elderly has grown significantly, namely depression. Depression is a disorder that is characterized by sadness, changes in appetite, altered sleep pattern, feeling of dejection or hopelessness and sometimes suicidal tendencies. It can occur at any age; however it is the most common mental health disorder in later life. The etiology of this psychiatric disorder may be due to genetic predisposition, negative life events and chemical imbalances, therapeutic and recreational drugs.

Depression may also accelerate the course of concurrent illness and amplify cognitive impairment and functional disability in the elderly.

Depression is a silent disorder, which is difficult to be detected especially in the elderly. This is because the elderly do not present with typical symptoms of depression such as lack of energy, loss of appetite, constipation, no interest in work, poor sleep or loss of weight.

However, depression contributes to increase medical morbidity and mortality, reduces quality of life and elevates health care costs. Therefore early diagnosis and effective management are required to improve the lives of those suffering from depression.

The objective of this study was to determine the prevalence of depression among the elderly in an urban area of the state of Selangor, Malaysia and to determine the factors associated with depression.

Depression is a serious, widespread, yet treatable medical condition that affects the quality of life of older people living in long-term residential care. There is general consensus that the prevalence of depression among this population is higher than that found in the older population in the general community (National Institute of Health Consensus Conference, 1992). However, the prevalence estimations reported in the literature vary widely, and there is a particular gap in our knowledge of depression among those residents with cognitive impairment, who are often excluded from research studies The present study investigated the prevalence of Major Depressive Disorder (MDD) among a sample of low-level care residents with and without mild or moderate cognitive impairment, and investigated the rates at which depression had been recognized and treated by their General Practitioner (GP). The impact of cognitive impairment on the prevalence and detection of depression among older residents was a particular focus of this study.

There are two types of residential care in Australia: high-level care (with facilities known as nursing homes) and low-level care (with facilities known as hostels). The majority of studies into the prevalence of depression have been conducted in nursing homes, with recent research findings estimating the prevalence of MDD among nursing home residents ranging from 9% to 26% (Baker & Miller, 1991; Blank et al., 2004; Gerety et al., 1994; Teresi et al., 2001). However, approximately one third of all aged care residents in Australia were classified as low-level care in 2004 (Australian Institute of Health and Welfare, 2005). Low-level care residential facilties typically offer individual rooms for residents and 24 hour staffing, mostly by nursing assistants (known as personal care assistants), but a small number of Registered Nurses may also be employed. In these settings, residents are usually frail and may require some minimal nursing care, but can often engage in self-care activities more independently than nursing home residents. There are preliminary indications that depression may also be a significant issue in low-level care residential facilities, with Bagley et al. (2000) reporting similarly high rates of self-reported depression across both low- and high-level residential facilities. Further research in low-level care settings is required, particularly research that examines the association between depression and the presence of cognitive impairment.

Studies investigating the association between the severity of cognitive impairment and depression have produced mixed findings, with a review article suggesting that opinion continues to be divided on this issue (Ballard et al., 1996). To illustrate, some studies have reported a higher prevalence of depression among those dementia sufferers with minimal cognitive impairment than among those with more severe impairment (Evers et al., 2002; Forsell & Winblad, 1999). In contrast, Teresi et al. (2001) reported that major depression was more prevalent among residents with moderate or severe cognitive impairment than among other residents. Meanwhile, Bruce et al. (2002) reported no difference in level of cognitive function between home care recipients with and without major depression. Due to the numerous inconsistencies in the literature, it is currently unclear if older people with mild or moderate cognitive impairment are at differential risk of a depressive illness than those with normal cognitive function. Further investigation of the prevalence of depression among older persons with and without cognitive impairment is warranted.

There is evidence that depressive illness frequently goes undetected among older populations (Crawford et al., 1998; Arve et al., 1999; Garrard et al., 1998). It may be expected that depression among individuals who are cared for within a residential facility – which specializes in the care of older persons – may be more likely to be detected than depression among older people living alone in the community, particularly given that residential staff are typically responsible for contacting residents’ GPs with concerns about their health. However, recognition rates have appeared to be comparable, with less than one third to one half of those with depression receiving treatment (Phillips & Henderson, 1991; Rovner et al., 1991; Teresi et al., 2001). High rates of cognitive impairment within residential care settings may impede the detection of depression by primary health services, in line with the finding by Evers et al. (2002) that depressed residents with more severe cognitive impairment were less likely to be recognized than other depressed residents.

Early detection and treatment of depression among aged care residents is important. Depression among older people residing in aged care facilities has been associated with an increased likelihood of transfer from low-level care to a nursing home or hospital (Kopetz et al., 2000; Watson, et al., 2003), and increased nursing staff care time (Fries et al., 1993). It has also been suggested that untreated depression in late life is likely to result in a chronic depressive illness, with a poor prognosis for complete recovery (Rovner et al., 1991). These findings highlight the need to investigate factors that may impact on detection and treatment of depression.

The present study aimed to determine the prevalence of depression among a sample of Australian low-level aged care residents, including those with normal cognitive function and those with mild and moderate cognitive impairment. In contrast to much of the previous research within low-level care residential settings which relied on self-report questionnaires, in the current study a clinical diagnosis of MDD was determined through DSM-IV criteria (American Psychiatric Association [APA], 1994). This study also evaluated treatment rates for depression by GPs, as well as any indication in participants’ medical files that symptoms of depression had been detected. It was hypothesized that cognitive impairment would be associated with low rates of detection and treatment of depression.

ABOUT DEPRESSION IN ELDERLY:
It is well known that changes occur in the body as a person ages. Older people are more prone to certain illnesses. The elderly are also at greater risk of being depressed, which is one of the leading causes of suicide in the older population. According to the Centers for Disease Control and Prevention, people 65 years of age and older make up 12 percent of the American population, but in 2004 accounted for 16 percent of suicide deaths. Many laypersons and professionals are not aware that depression is a medical illness or confuse the symptoms with dementia. Further, some elderly are embarrassed about being ill or are concerned about being stigmatized. Instead of saying that they are depressed, they blame their problem on a medical illness.

INCORRECT ASSUMPTION
The National Institute of Mental Health (NIMH) reports that mental illness is a "widely under-recognized and undertreated medical illness." Studies find that many older adults, as many as 75 percent, saw a doctor less than a month before committing suicide. Such results stress the critical importance of the detection and treatment of depression by the health care providers.

PHYSICAL AND MENTAL ILLNESS CO-OCCURRENCE
The NIMH also reports that the risk of elderly depression is greater with other illnesses and decreased ability to function. Health care providers need to be more cognizant of the co-occurrence of illness and depression, so the two problems can be treated separately.

This finding is also associated with the increase of depression of older individuals who require health care support or need to live in a elder-care facility. Older people who live on their own have a 1 percent to 5 percent risk of depression. However, this number rises to 13.5 percent with those who need home health care and 11.5 percent for those who are in the hospital.

ADDITONAL RISK FACTORS
In addition to becoming ill, there are a number of other factors that may cause depression in the elderly. Health care providers also need to be cognizant of these increased risks. Depression is more associated with women than men. Also, individuals more prone toward the illness are living alone, facing a great deal of stress in their lives, taking medications with depressive side effects, and coping with their body image from, for example, an amputation, heart attack or cancer. They have been depressed in the past and may have previously attempted suicide. Depression also is often genetic and runs in families. Recent studies are also recognizing the impact of insomnia on mental health.

NEUROIMAGING OFFERING NEW INSIGHTS
According to a report by Dr. Frank Kozel at the Medical University of South Carolina, neuro imaging, or brain scans, of the elderly depressed offer "an exciting opportunity" for treatment. For example, the brain scans of individuals who become depressed for the first time when they become older show areas where there may be an inadequate flow of blood. These cells may be undergoing chemical changes that increase the chance of depression.

A great deal of work is being done in neuroimaging, such as studying brain changes along with different depression treatments, such as medicine, cognitive-behavioral therapy, sleep deprivation, and shock therapy. Although most studies are only in the research stages, it is expected that these results will be able to help elderly depression in the future.

DISTINCTION BETWEEN DEPRESSION AND DEMENTIA:
Left alone, depression not only prevents older adults from enjoying life like they could be, it also takes a heavy toll on health. But if you learn how to spot the signs of depression and find effective ways to help, you or your loved ones can remain happy and vibrant throughout the golden years.
Depression is a problem for many older adults

Loss is painful—whether a loss of independence, mobility, health, your long-time career, or someone you love. Grieving over these losses is normal, even if the feelings of sadness last for weeks or months. Losing all hope and joy, however, is not normal. It’s depression.

If you have depression, you are not alone. According to the National Institutes of Health, of the 35 million Americans age 65 or older, about 2 million suffer from full-blown depression. Another 5 million suffer from less severe forms of the illness.

DEPRESSION OR DEMENTIA
Depression and dementia are often confused in older people, and the conditions can coexist. Feeling sad, lonely, or socially isolated is not uncommon as we age, or at any age. Everyone gets the blues at times and has days where getting out of bed seems like too much. When depression is a clinical issue, feelings of hopelessness, dread, and sadness last for several days, preventing one from participating in ordinary life and previously pleasurable activities, and might lead to suicide. It’s helpful to meet with someone if you suspect depression or dementia in yourself or a loved one because the symptoms are not always clear--research shows that many elderly don’t think of themselves as sad, although other signs of depression are present. These include anxiety; agitation; physical complaints that don’t have an organic basis; isolation from others; feelings of confusion, delusions, or hallucinations; loss of self worth; and fatigue or no energy, as well as overeating, underrating, and having difficulty with sleep.

Loss of cognitive or reasoning functions due to dementia can also look like depression--confusion can appear as sadness, recognition of cognitive losses can lead to low self-esteem, and alcohol abuse can mask signs of both.

Talking with a professional for both assessment and counseling can help.When senior citizens become depressed, agitated, or show signs of dementia, it is often difficult to know what the best ways to keep them healthy and happy are. Before you consider long-term care as a solution, there are things you can do to keep your loved ones in their homes.

According to the American Association for Geriatric Psychiatry (AAGP), nearly 20 percent of those who are 55 years and older have mental disorders that are not part of normal aging. Some of the most common illnesses are anxiety, severe cognitive impairment and mood disorders. Jeffery Lafferman, M.D., a psychiatrist at Levindale Hebrew Geriatric Center and Hospital’s Partial Hospitalization Program and Outpatient Services, says that too often mental health illnesses are underreported. “As people age, their health needs become more complicated. Medical problems, such as high blood pressure and arthritis, are common and can mask the emotional challenges that the elderly face, until it has reached a critical stage.”

But there is help and hope available. One of the ways to keep an elderly loved one at home for as long as possible when they are experiencing depression, dementia, agitation and other emotional challenges is through day treatment programs.

“Some adult day services programs are specifically designed to help elders relearn how to again be a useful part of their communities. The programs have group and individual therapy sessions in a stimulating environment. In addition, participants can reminisce with people their own age, take part in activities designed to renew their enthusiasm for life and be in their own homes in the evening,” says Dr. Lafferman.

Many people do not understand that clinical depression and other mental illnesses are treatable. Some of the symptoms to look for are a change in personality, a decline in memory, isolation from friends and family, excessive feelings of guilt or hopelessness, frequent crying, sleep problems, unexplained physical illnesses, loss of function, changes in appetite, loss of interest in personal hygiene and irritability, and anxiety.

However, Dr. Lafferman advises, “Before you entrust your loved one to any program, try to visit to see with your own eyes what the program is like. Although your elder loved one needs supervision, his or her dignity must be preserved. In addition, check to see if there are medical professionals on site, and if there are different therapies to engage them.”

When a loved one is experiencing emotional issues, it can also affect the whole family, so giving caregivers a break during the day is also important.

(Source: LifeBridge Health,20 Agust 2009)

FRANK’S STORY
Frank is a 74-year-old widower. He used to be quite active, volunteering his time at the local community center, playing golf with his buddies at least once a week, and enjoying frequent get togethers with his grown children and grandkids. But since his wife Ruth passed away, he’s lost all interest in getting out or seeing anyone. It’s been nine months since his loss, but Frank shows no sign of feeling better.

To his friends and family, Frank seems like a different person. He’s not the lively man they used to know, always cracking jokes, telling stories, or starting a new project. Now he seems to walk and talk in slow-motion. He doesn’t even leave home most days and he avoids phone calls and visitors. Even more concerning is his rapidly deteriorating health. Frank’s diabetes used to be under control, but not anymore. Making matters worse, he often skips meals or forgets to take his insulin shots.

Although depression in the elderly is a common problem, only a small percentage get the help they need. There are many reasons depression in older adults is so often overlooked: Some assume seniors have good reason to be down or that depression is just part of aging. Elderly adults are often isolated, with few around to notice their distress. Physicians are more likely to ignore depression in older patients, concentrating instead on physical complaints. Finally, many depressed seniors are reluctant to talk about their feelings or ask for help.

The consequences of this oversight are high. Untreated depression poses serious risks for older adults, including illness, alcohol and prescription drug abuse, a higher mortality rate, and even suicide. So it’s important to watch for the warning signs and seek professional help when you recognize it. The good news is that with treatment and support, depressed seniors can feel better. No one, whether they’re 18 or 80, has to live with depression.

DEPRESSION WITHOUT SADNESS
Older adults don't always fit the typical picture of depression. Many depressed seniors don’t claim to feel sad at all. They may complain, instead, of low motivation, a lack of energy, or physical problems. In fact, physical complaints, such as arthritis pain or headaches that have gotten worse, are often the predominant symptom of depression in the elderly.

Older adults with depression are also more likely to show symptoms of anxiety or irritability. They may constantly wring their hands, pace around the room, or fret obsessively about money, their health, or the state of the world.

Depression Clues in Older Adults

Older adults who deny feeling sad or depressed may still have major depression. Here are the clues to look for:

Unexplained or aggravated aches and pains

Hopelessness

Helplessness

Anxiety and worries

Memory problems Loss of feeling of pleasure

Slowed movement

Irritability

Lack of interest in personal care (skipping meals, forgetting medications, neglecting personal hygiene)

Adapted from American Academy of Family Physicians

DEMENTIA vs. DEPRESSION:

Never assume that a loss of mental sharpness is just a normal sign of old age. It could be a sign of depression or dementia, both of which are common in the elderly. But since depression and dementia share many similar symptoms, including memory problems, sluggish speech and movements, and low motivation, it can be difficult to tell the two apart. There are, however, some differences that can help you distinguish between the two.

Is it Depression or Dementia?

Symptoms of Depression

Mental decline is relatively rapid

Knows the correct time, date, and where he or she is

Difficulty concentrating

Language and motor skills are slow, but normal

Notices or worries about memory problems.

Symptoms of Dementia

Mental decline happens slowly

Confused and disoriented;

becomes lost in familiar locations

Difficulty with short-term memory

Writing, speaking, and motor skills are impaired

Doesn’t notice memory problems or seem to care



Whether the cognitive decline is caused by dementia or depression, prompt diagnosis and treatment arekey. If it’s depression, memory, concentration, and energy will bounce back with treatment. Treatment fordementia will also improve you or your loved one’s quality of life. And in some types of dementia,

symptoms can be reversed, halted, or slowed.
5)Is Lifestyle Influencing Morbidity among Elderly?
Ageing is an irreversible process. In the words of Seneca, “old age is an incurable disease”. More recently Sir James Sterling Ross commented, “you do not heal old age, you protect it, you promote it and you extend it”. Expectation of life at birth has increased in recent years. The expected life projected in 2011 – 2016 has been 67 years for male and 69 years for female. United Nation has indicated that 21% of the Indian population will be above 60 years by 2050.


Industrialization, urbanization, education and exposure to western life style are bringing changes in values of life. Despite the strong family ties in India in general and Kashmir valley in particular, the old age population has become vulnerable due to which they become distressed and depressed.

In the valley of Kashmir, people leave their homes for the greener postures to different cities even outside the country to seek better employment leaving behind the aged ones to fend for themselves.

Old age is not a disease in itself but the elderly are vulnerable to long term diseases of insidious onset such as cardiovascular diseases, cancer, diabetes, musculoskeletal and mental disorders. There are multiple symptoms due to decline in the functioning of various body functions. According to Unani System of Medicine the temperament above the age of 60 is cold and wet, and it is due to the lowered Hararat-e-Garizia giving rise to different ailments. Thus different diet pattern and mashaikh have been prescribed for the aged ones in the Unani Classics.

6)Aging changes in organs - tissue - cells

MedlinePlus Topics

Seniors' Health

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Tissue types

All vital organs begin to lose some function as you age. Aging changes have been found in all of the body's cells, tissues and organs, and these changes affect the functioning of all body systems.

Living tissue is made up of cells. There are many different types of cells, but all have the same basic structure. Tissues are layers of similar cells that perform a specific function. The various kinds of tissues group together to form organs.

There are four basic types of tissue:

• Connective tissue supports other tissues and binds them together. This includes bone, blood, and lymph tissues in addition to the tissues that give support and structure to the skin and internal organs.

• Epithelial tissue provides a covering for deeper body layers. The skin and the linings of the various passages inside the body are made of epithelial tissue.

• Muscle tissue includes three types of tissue:

o Striated muscles, such as those that that move the skeleton (also called voluntary muscle)

o Smooth muscles (also called involuntary muscle), such as the muscles that surround the stomach and other internal organs

o Cardiac muscle, which makes up most of the heart wall (also involuntary muscle)

• Nerve tissue is made up of nerve cells (neurons) and is used to carry messages to and from various parts of the body. The brain is made of nerve tissue.

AGING CHANGES
Cells are the basic building blocks of tissues. All cells experience changes with aging. They become larger and are less able to divide and reproduce. Among other changes, there is an increase in pigments and fatty substances inside the cell (lipids). Many cells lose their ability to function, or they begin to function abnormally.
Waste products accumulate in tissue with aging. A fatty brown pigment called lipofuscin collects in many tissues, as do other fatty substances.
Connective tissue changes, becoming increasingly stiff. This makes the organs, blood vessels, and airways more rigid. Cell membranes change, so many tissues have more trouble receiving oxygen and nutrients and getting rid of carbon dioxide and wastes.
Many tissues lose mass. This process is called atrophy. Some tissues become lumpy (nodular) or more rigid.
Because of cell and tissue changes, your organs also change as you age. Aging organs gradually but progressively lose function, and there is a decrease in the maximum functioning capacity. Most people do not notice this loss, because you seldom need to use your organs to their fullest capability.

Organs have a reserve ability to function beyond the usual needs. For example, the heart of a 20-year-old is capable of pumping about 10 times the amount that is actually needed to preserve life. After age 30, an average of 1% of this reserve is lost each year.

The most significant changes in organ reserve occur in the heart, lungs, and kidneys. The amount of reserve lost varies between people and between different organs in a single person.

These changes appear slowly and over a long period of time. Even so, when an organ is worked harder than usual it may not be able to increase function. Sudden heart failure or other problems can develop when the body is worked harder than usual. Things that produce an extra workload (body stressors) include the following:

• Certain medications

• Illness

• Significant life changes

• Suddenly increased physical demands on the body, for example:

o A sudden change in activity

o Exposure to a higher altitude

Loss of reserve also makes it harder to restore equilibrium in the body. Drugs are detoxified at a slower rate. Lower doses of medications may be needed, and side effects become more common.

Medication side effects can mimic the symptoms of many diseases, so it is easy to mistake a drug reaction for an illness. Some medications have entirely different side effects in the elderly than in younger people.

AGING THEORY
No one really knows how and why people change as they get older. Some theories claim that aging is caused by accumulated injuries from ultraviolet light, wear and tear on the body, by-products of metabolism, and so on. Other theories view aging as a predetermined, genetically-controlled process.

However, no theory sufficiently explains all the changes of the aging process. Aging is a complex and varied process that varies in how it affects different people and even different organs. Most gerontologists (people who study aging) feel that aging is the cumulative effect of the interaction of many lifelong influences. These influences include heredity, environment, cultural influences, diet, exercise and leisure, past illnesses, and many other factors.

Unlike the changes of adolescence, which are predictable to within a few years, each person ages at a unique rate. Some systems begin aging as early as age 30. Other aging processes are not common until much later.

Although some changes typically occur with aging, they occur at different rates and to different extents. There is no reliable way to predict specifically how you will age.

TERMS

• ATROPHY

o Cells shrink. If enough cells decrease in size, the entire organ atrophies. This is often a normal aging change and can occur in any tissue. It is most common in skeletal muscle, the heart, the brain, and the secondary sex organs (such as the breasts).

o The cause of atrophy is unknown, but may include reduced use, decreased workload, decreased blood supply or nutrition to the cells, and reduced stimulation by nerves or hormones.

• HYPERTROPHY

o Cells enlarge. This size increase is caused by an increase in cellular proteins, such as the cell wall and internal cell structures, not an increase in the cell's fluid.

o When some cells atrophy, others may hypertrophy in an attempt to compensate for loss of cell mass.

• HYPERPLASIA

o The number of cells increases. There is an increased rate of cell division.

o Hyperplasia usually occurs in an attempt to compensate for loss of cells. It allows some organs and tissues to regenerate, including the skin, the lining of the intestines, the liver and the bone marrow. The liver is especially good at regeneration. It can replace up to 70% of its structure within 2 weeks after an injury.

o Tissues that have limited ability to regenerate include bone, cartilage, and smooth muscle (such as the muscles around the intestines). Tissues that seldom or never regenerate include nerves, skeletal muscle, heart muscle, and the lens of the eye. When injured, these tissues are replaced with scar tissue.

• DYSPLASIA

o The size, shape, or organization of mature cells becomes abnormal. This is also called atypical hyperplasia.

o Dysplasia is fairly common in the cells of the cervix and the lining of the respiratory tract.

• NEOPLASIA

o The formation of tumors, either cancerous (malignant) or noncancerous (benign).

o Neoplastic cells often reproduce rapidly. They may have unusual shapes and abnormal function.

7)Ageing and Sociology

The Department of Sociology at McMaster University has a dynamic research program in many areas, such as ethnography, research methods, education, health, gender, family, aging, social constructionism, race and ethnicity, immigration, social class, politics, organizations, professions, work, occupations, deviance, the body, religion, media, sports, culture, science, the internet, technologies, and knowledge. Many faculty members have external research grants which provide opportunities to graduate students for research training, additional funding, potential theses, and new areas of learning. Students should look at this research section when looking for such opportunities or, more generally, when searching for faculty members who most closely match their own research interests.

Aging is an applied interdisciplinary program in Sociology. The main approaches are the life course, the interpretive perspective, and critical gerontology/political economy. Research and study employ both quantitative survey and qualitative methods. We attempt to untangle such thorny issues as chronological age, historical periods, and birth cohort effects. The linkages between aging and health are a particular strength of the Department. The Department offers both undergraduate and graduate courses in aging and social gerontology. Students are able to take one of their doctoral comprehensive examinations in this area and to write MA theses and Ph.D. theses in the sociology of aging. They are ably guided by Drs. Lori Campbell and Margaret Denton, both of whom are cross-appointed between Sociology and Gerontology.

Dr. Lori Campbell specializes in aging and family relationships, men's filial care giving, family inheritance, sibling ties in middle and later life, and marital status transitions. Her current research, funded by the Social Sciences and Humanities Research Council of Canada, involves a qualitative study of the experience and meaning of inheritance within families. She is also continuing an analysis of data from her study of adult son caregivers.

Dr. Margaret Denton specializes in the sociology of aging, formal care giving, health and aging, community health and social services, long-term care, supportive housing, retirement and income inequality, and gender differences. She is a co-investigator on the Social and Economic Dimensions of an Aging Population research project funded by the Social Sciences and Humanities Research Council of Canada.
Dr. Denton is also doing research on access to community based services for seniors and continues her research on gender differences in health.

8)Effects of Aging on Skin

The lines engraved on your face may have once told the story of your life, but this doesn't have to be the case. Your face no longer has to give away your age. Sure, aging will affect your skin, but there are ways to slow down the hands of time.

What Causes Wrinkles
a. You may think that wrinkles are inevitable part of aging, but they're not. Understanding what causes wrinkles is the first step to warding off the effects of aging on your skin. Your skin gets its strength and resiliency from elastin and collagen. Unfortunately, these fibers tend to break down more and more as you age, making it harder and harder for your skin to replenish damaged skin cells with newer ones. This is what makes your skin look wrinkly, crinkly and even saggy.

At the same time your skin is slowing its elastin and collagen production, the capillaries and nerves in the skin also begin to die away, which lets gravity pull the epidermis down deep into the dermal layer of the skin. This causes the upper layers to thin out. To make matters worse, the sebaceous glands produce less natural oils, which can cause drying, which accelerates the entire skin aging process. That's why those fine lines you noticed in your 30s became more pronounced in your 40s. The key to warding off the effects of aging on your skin is to give it what it needs most: plenty of vitamins, minerals, water and moisturizer.

The Change Begins at 30

b. For most women, the first telltale signs of aging comes in their 30s, while men fair much better, with wrinkles and age spots staying away until their late 40s or beyond. As the skin begins to make less and less elastin and collagen, the substances that keep it taut and smooth, small wrinkles and creases may appear.

If you were a sun worshiper in your younger years, you may notice more than a few laugh lines or crinkles around the eyes, with deeper crow's feet, wrinkles, dark spots or even some sagging neck skin making their presence known.

Some things that both men and women can do to keep their skin from aging prematurely include moisturizing regularly; eating a well balanced diet; avoiding harsh skin care products and chemicals; staying properly hydrated and relaxing more. Stress can be a big wrinkle inducer in men especially.

How Your 40s Can Affect Your Skin

c.Hormone fluctuations create some real changes in a woman's skin in her 40s. Oily skin may suddenly turn bone dry, acne may reemerge and a once creamy smooth complexion may darken or begin to wrinkle.

Men often see the affects of aging on their forehead, with the sudden appearance of thin lines. This is caused by relaxing muscle fibers in your skin and shrinking fat cells caused by a decrease in collagen production.

Some great ways everyone can slow down the aging process in your 40s is to apply sunscreen daily underneath your moisturizer; avoid harsh cleansers, opting instead for milk based creams; using a good antioxidant moisturizer daily; using a hydrating facial steam at least once a week and making frequent skin checks for any unusual moles, tags or discoloration to catch any skin cancer early.

The Fabulous 50s

d. Most men begin to experience their first sign of real wrinkles in their 50s, while women lose their natural skin glow as their estrogen levels drop. Both sexes may notice their skin beginning to look and feel looser around the eyes, nose, jaw and throat. The cheekbones often become more pronounced now as the skin becomes thinner and thinner. One of the best ways to face the skin problems of the 50s is to dry brush your skin regularly to help stimulate epidermal growth and get rid of dry, dead skin cells.

The Sensational 60s e
 Lost muscles tone caused by skin layer shrinking in your 60s often deepens wrinkles and makes the skin and eyes sag. The three most important things your can do to reduce the affects of aging on your skin at this point of your life is to drink plenty of water, eat lots of fresh fruits and vegetables and keep your skin moisturized.

Older Skin

f.The skin of your 70s, 80s and beyond isn't going to be the youthful skin of your 20s or 30s, but it can remain looking young and healthy. There will be wrinkles, but it can keep some of its tone, no matter what your age. Be sure to pamper your skin in your later years with dry brushing and moisturizing with a luxuriating bath of avocado, hazelnut, jojoba, almond, sesame or coconut oils. Men need to take special care to apply sunscreen when outdoors to both protect and moisturize their skin.

9)INTERNATIONAL FEDERATION ON AGEING THE MONTREAL DECLARATION


This document is the result of more than a year of deliberations and input from member groups of the International Federation on Ageing throughout the world. A draft was presented and reviewed at the IFA Fourth Global Conference on Ageing in Montreal, Canada. More than 1200 participants from 68 countries were involved in the final editing of the document. It was officially released and turned over to the United Nations Aging Unit at the closing plenary session of the Conference on Wednesday, September 8, 1999.

Preamble

The world is facing unprecedented demographic change. In the next 30 years the world’s population of older persons is expected to triple, with much of this increase- taking place in developing countries. All societies are enriched by their older people and demographic change will increase the potential for even greater benefits. Ageing is a natural process of life. Older persons are a valuable resource. They are the repositories of tradition, culture, knowledge and skills. These attributes are essential in maintaining intergenerational links.

The vast majority of older persons make vital contributions to their societies, families and communities as workers, caregivers, volunteers, mentors and as active citizens. There is an increase in inequalities between developing and developed countries, between rural and urban environments and within individual countries.

The United Nations and its member states need to develop strategies with realistic goals and measurable objectives so as to ensure that the world’s population ages well and that older persons’ needs for a secure and productive future are met.
As we assemble in Montreal in September 1999 at the Fourth Global Conference of the International Federation on Ageing, we note with concern that the 1991 UN Principles for Older Persons are still not universally recognized nor adhered to; neither has the 1982 Vienna International Plan of Action been fully implemented.
Therefore, We, the older people throughout the world, our families and colleagues, universally call upon the United Nations and its agencies to work with national governments, non- overnmental organizations, the corporate, private and voluntary sectors, in addressing the following urgent issues.

Issues

Many older persons throughout the world lack access to the essentials of life as the result of discrimination on the basis of age, disability, ethnicity, race, gender or religion, or because of employment practices and legislative barriers. Women, as the majority of the ageing population, suffer disproportionately from Older persons with disabilities face cultural and socio-economic barriers which impact on their quality of life.

Developing countries face the most rapid rate of population ageing and the greatest economic difficulties, but lack the necessary financial, social and health infrastructures to address these issues. The devastating effects of conflict and illnesses such as AIDS have drastically altered the population structure of some countries, exposing older persons to greater vulnerability. Changes in family patterns, structures and life styles can have a detrimental impact on older persons.

Principles
We reaffirm the 1982 Vienna International Action Plan on Ageing, then the 1990 IFA eclaration of Rights and Responsibilities of Older Persons, and the 1991 UN Principles for the Elderly. Older persons have the right to self-determination and fulfillment, dignity and respect, personal security, freedom of speech, association, and religious expression. Older persons have the right of access to work, income, health care and shelter. The responsibilities of older persons include contributing to the realization of these rights by participating in the political processes of their community in accordance with UN democratic principles. The empowerment of older persons necessitates their recognition as full participants and equal citizens in society.

Recommendations

We, the older persons of the world:

Call upon the United Nations General Assembly in this era of rapid ageing of the world’s population to declare a Decade of Older Persons;

Call upon on the United Nations to strongly urge each member state to adopt a National Plan on Ageing (as suggested in the UN National Targets on Ageing) that must include older persons in its development and strategies for
 implementation. National Plans should pay special attention to issues of gender, ethnicity, and diversity;

Call upon the United Nations to convene a World Assembly on Ageing in five years to review the progress achieved by individual member states in the
 adoption and implementation of their National Plan on Ageing;

Call upon the United Nations to assure that ageing concerns be systematically incorporated into the agendas, products and research of all relevant United Nations commissions, committees, consultations, plans of action, and programs; and that issues of ageing be a major component in the development agenda;

Call upon the United Nations to expand the human and financial resources for the UN Program on Ageing and for other UN agencies whose programs impact on ageing.

Recommend to the United Nations that all National Plans on Ageing:

Assure the universal access of older persons to economic security, food, health care, shelter, clothing and transportation.

Assure the full participation of older persons in the social, cultural and political life of their communities.

Assure that the dignity and quality of care for older persons are established,

maintained and safeguarded, and that older persons are free from exploitation

and mental and physical abuse.

Assure that employment barriers for older persons are eliminated by the

provision of training and work opportunities and appropriate work conditions.

Strengthen the capacity of the family and community to provide basic care and support for older persons.

Strengthen opportunities for intergenerational dialogue, exchanges, collaboration and mentoring.

Incorporate Universal Design principles to assure older persons access to all environments.

Strengthen the ability of the public, private, voluntary, and non-governmental sectors to work together for the benefit of older persons.
September 1999

10)Elder Abuse


There has been growing awareness over recent years of the prevalence of elder abuse. Just as children are at higher risk of abuse because they are not physically or emotionally able to defend  themselves, frail older people may be at risk for similar reasons (Westhorp et al., 1997).
It has been estimated that, in Australia, between 2 and 5 per cent of people over the age of 65 are at risk of or have experienced some form of abuse (Westhorp et al., 1997). Elder Abuse crosses national, class, religious and cultural boundaries. Both men and women are abused, and older people who are physically and mentally fit are subject to abuse as well as the frail and dependent (Valsler, 1996). The abuse of older people may include physical, sexual, and emotional mistreatment, financial exploitation, neglect of basic needs and enforced isolation. Elder abuse is defined as the wilful or unintentional harm caused to a senior by another person with whom they have a relationship implying trust (adapted from Hailstones, 1992). Abuse may be carried out by an individual, for example, a family member caring for an older person; or a number of people. The entire workforce of an organisation may be guilty of abusing all clients due to attitudes and practices which fail to recognise basic human rights, such as the right to privacy, to make choices and to be considered and treated as an individual (Valsler, 1996). In the case of financial abuse, an otherwise fit and independent older person may be taken advantage of by a carer, friend or relative. The abuse may involve misappropriation of their money, valuables or property; forcing or intimidating them into changing their will or other legal documents, or denying them access to or control over their personal finances (Hailstones, 1992).
Evidence has shown that elder abuse may be influenced by the following factors - carer stress, dependency, a history of family conflict, isolation, psychological problems, and substance abuse, with 85 per cent of people abused by people who know them (American Psychological Association, 1999). In the context of residential care, studies have shown that abuse is more likely to occur in institutions where the approach by staff has become depersonalised and dehumanised to the extent that the older person is viewed as an object rather than a human being (Valsler, 1996). Recent media reports of incidences in which seniors have been treated appallingly in nursing homes has raised an awareness of the vulnerability older people in residential aged care. Incidents such as residents being subject to kerosene baths and being trapped in a closet for 5 days have highlighted the need for older people's rights to be more stringently safeguarded. Many different factors have been blamed for the abuses which have taken place, including lack of staffing and staff training, lack of funding, and negative stereotypes of older people which leadthem to be depersonalised and treated in a paternalistic manner, as if the system knows best. There is a clear need for an advocacy response to the plight of these vulnerable seniors that supports their rights without being over protective and patronising. Advocacy agencies, seniors groups and people in the aged care sector must work with older people to support their rights and best interests. In Western Australia, people over the age of 60 currently represent 14 per cent of the population. It has been estimated that by the year 2021, 22 per cent of the state's population will be composed of older people (Office of Seniors' Interests, 1998a). The ageing of the population has largely come about as a consequence of increasing longevity and declining birthrates (Office of Seniors' Interests, 1998a).